Nursing Elites

1. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation?

• A. Anorexia
• B. Bradycardia
• C. Sudden relief from pain
• D. Decreased abdominal distention

Correct answer: C

Rationale: When caring for a child with probable appendicitis, sudden relief from pain is a critical sign that could indicate perforation of the appendix. Perforation results in the release of pressure and inflammation, leading to a temporary relief of pain. Anorexia (loss of appetite) and decreased abdominal distention are symptoms commonly associated with appendicitis itself, not perforation. Bradycardia (slow heart rate) is not typically a direct manifestation of appendicitis or its complications.

2. The clinic nurse is teaching parents about physiologic anemia that occurs in infants. What statement should the nurse include about the cause of physiologic anemia?

• A. Maternally derived iron stores are depleted in the first 2 months.
• B. Fetal hemoglobin results in a shortened survival of red blood cells.
• C. The production of adult hemoglobin decreases in the first year of life.
• D. Low levels of fetal hemoglobin depress the production of erythropoietin.

Correct answer: B

Rationale: Physiologic anemia is caused by the transition from fetal to adult hemoglobin, with fetal hemoglobin having a shorter lifespan, leading to a temporary decrease in red blood cells.

3. The parent of a 1-month-old infant voices concern about the infant’s respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?

• A. The normal respiratory rate for an infant at this age is between 20 and 30 breaths per minute.
• B. The respirations of a 1-month-old infant are normally irregular and periodically pause.
• C. An infant at this age should have regular respirations.
• D. The irregularity of the infant's respirations is concerning; I will notify the health care provider.

Correct answer: B

Rationale: The correct answer is B. Irregular respirations with periodic pauses are normal in a 1-month-old infant. Choice A is incorrect because the normal respiratory rate for an infant at this age is higher than the range provided. Choice C is incorrect as irregular respirations are expected in infants. Choice D is not appropriate as irregular respirations with periodic pauses are a normal finding in young infants and do not necessarily indicate a concern that requires immediate notification of the healthcare provider.

4. Which electrolyte imbalance is a common concern in children with severe diarrhea?

• A. Hypernatremia
• B. Hypokalemia
• C. Hypercalcemia
• D. Hypomagnesemia

Correct answer: B

Rationale: Hypokalemia is the correct answer because it is a common concern in children with severe diarrhea. Diarrhea can lead to significant potassium loss, resulting in hypokalemia. Hypernatremia (Choice A) is less common in diarrhea as sodium concentration is usually diluted by the fluid loss. Hypercalcemia (Choice C) is not typically associated with severe diarrhea. Hypomagnesemia (Choice D) can occur but is not as common as hypokalemia in this scenario.

5. According to Piaget, which principle supports a nine-year-old child's understanding that an arm will look the same when the IV is removed?

• A. The principle of conservation
• B. The principle of transductive reasoning
• C. The principle of identity
• D. The principle of reflex abilities

Correct answer: A

Rationale: The correct answer is A, the principle of conservation. Piaget's principle of conservation relates to a child's ability to understand that certain properties of objects remain unchanged despite modifications in their appearance. In this case, the child's understanding that an arm will look the same after the IV is removed demonstrates conservation of appearance. Choice B, transductive reasoning, involves making faulty generalizations based on specific instances and does not apply in this context. Choice C, the principle of identity, pertains to recognizing objects as the same even if they undergo transformations, which is not directly relevant to the scenario. Choice D, reflex abilities, refers to automatic responses to stimuli and is unrelated to the child's understanding of the arm's appearance post-IV removal.

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